PATIENT AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION TO MOUNT SINAI

Please request/check all that apply:

I authorize  

 to disclose medical information about my:

 Emergency Room visit on: 

 
Date(s)

 OPD Clinic visit, specify clinic:  

 
Date(s)

 FPA Practice/Provider  

 Hospitalization from:  

 Ambulatory Surgery:     Date: 

 Specify (i.e. Lab tests, Operative Reports) 

   
   
   
Mount Sinai Medical Center
One Gustave L. Levy Place 
New York N. Y. 10029 
     

We will not condition treatment or payment on whether you sign this authorization. However, if you refuse to sign we will not release your records.

  1. - Medical Records Copy
  2. - Patient Copy
MR-201P (10/11)

SPECIFIC UNDERSTANDINGS

I understand that this consent may include disclosure of Alcohol and Drug Abuse records and/or Psychiatric records and or HIV-related information (indicating that I have had an HIV-related test, or have HIV infection, HIVrelated illness or AIDS, or that could indicate that I have been potentially exposed to HIV).

If I am authorizing the release of HIV/AIDS, Alcohol or Drug treatment, or mental health treatment related information the recipient(s) is prohibited from redisclosing the information without my authorization unless permitted to do so under federal and state law. I also have a right to request a list of people who may receive or use my HIVrelated information without authorization. If you experience discrimination because of the release or disclosure of HIV-related information, you may contact the New York State Division of Human Rights at (800) 523-2437/(212) 480-2493 or the New York City Commission on Human Rights at (212) 306-7450.

By signing this authorization form, I am authorizing the use or disclosure of my protected health information as described above. This information may be redisclosed if the recipient(s)as described on this form is not required by law to protect the privacy of the information, and such information is no longer protected by federal health information privacy regulations.

 

To request records or to revoke authorization send a written request to:

  • Mount Sinai Hospital
  • Medical Records
  • One Gustave L. Levy Place - Box 1111
  • New York, NY 10029
  • Faculty Practice Associates
  • Patient Rights Coordinator
  • One Gustave L. Levy Place - Box 1621
  • New York, NY 10029
  • Mount Sinai Hospital Queens
  • Medical Records
  • 25-10 30th Avenue
  • Long Island City, NY 11102
  • Northshore Medical Group
  • Medical Records
  • 325 Park Ave
  • Huntington, NY 11743

For Mount Sinai Use Only

           
  1. - Medical Records Copy
  2. - Patient Copy
MR-201P (10/11)